Safely Reducing Avoidable Conveyance Programme

Falls Initial Response Skills Training (FIRST)

Brief Description of Initiative

Provision of training to ensure consistency and appropriate responses for patients who have fallen in residential or care homes.

Date Initiative was introduced in Trust

Winter of 2016 / 17.

Date of upload or review

Uploaded to Repository 1st January 2020.

Background Context

A high proportion of calls for ambulances received by NEAS relate to older residents. The 4th most common reason for requesting an ambulance relates to older residents who have had a non–injury fall, either in their own home or in a care or residential home. Whist a non-injury fall has a lower medical need, spending a great deal of time ‘on the floor’ presents a poor patient experience. Waiting a long time for assistance after a fall is one of the issues that is frequently highlighted by patients, carers and the media as a significant cause for concern. Such cases create a number of complaints for NEAS. A ‘long lie’ (i.e. laid immobile for >60 mins) is not a benign event. These patients have an increased risk of physical illness arising, such as rhabdomyolysis and pressure sores.

A specific issue for care and residential homes relates to the type of assistance available on site to patients. Where a home makes use of non-clinical staff, those staff are not able to make a clinical assessment of their patient’s condition. Where a patient is poorly, the best way to asses a patient’s condition will often be via a paramedic by a Double Crewed Ambulance attendance. Given that the position of older residents can deteriorate quickly, the safest outcome under such circumstances may be conveyance to the Emergency Department.

We have been working to deliver training with care and residential home staff on responding to falls, our view is this has made a visible difference in the level of ambulance responses to homes, so training makes a difference. This was funded initially from the UEC Vanguard, and then subsequently directly from CCGs as part of winter resilience schemes (for example). In our view, it would be helpful for there to be ongoing access to this sort of training, not least of all due to the level of staff turnover in care homes.

Which specific patient group or presenting need is this response targeted at?

Frail elderly in Care Homes who are at increased risk of falling.

Geographical area or location covered by this response model

North East and North Cumbria.

Key Aims
  • To assist Care Homes and their staff by providing the necessary training and education around Falls Prevention
  • To equip Care Home staff with the knowledge and skills needed for when someone has had a fall
  • The training would deliver a standardised approach to Falls Prevention Training and Education across the region
Benefits for Patients
  • Better care provision for residents and families through upskilling of care home staff
  • Prevention of falls for residents
Benefits for Trust or System
  • Reduced number of complaints relating to ‘long lies’
  • Overall, there is a benefit for our frail elderly, care home staff, front-line healthcare resources in the Trust and colleague secondary care organisations, and potentially a significant economic benefit for our CCG colleagues to realise across the North East and North Cumbria economy
  1. How long has this initiative been operational?
    The initiative has been operational on an ad-hoc funded basis since the winter of 2016/17, with the original NHSE Vanguard funding.  In total over the intervening period we have provided around 125 courses, with an average of eight delegates, and therefore have trained over 1,000 Care Home staff.
  2. Days / Hours of operation:
    There are no fixed hours of operation.  The course is a one-day training programme of six hours, which can be flexibly delivered as and when, or where, needed.
  3. Which clinicians are involved in the response and how many WTEs (if a specific cohort)?
    There are no clinicians involved in the delivery of the training.  The course was, however, developed with Paramedic and Consultant Paramedic guidance.
  4. Which other partners are involved in providing the response?
    There has been considerable support and engagement with North of England Commissioning Support (NECS), local CCGs and Local Authorities.
  5. What other key resources are needed for this response to work? (vehicles, specific equipment etc)
    N/a.  The course materials are all developed and routinely reviewed.
  6. How is the initiative funded? (level of engagement/support from CCGs etc)
    Funding from NECS, NHSE, and Local Authorities.  The course is not commissioned sustainably and is more invested in on an ad-hoc basis.
    Some Care Homes have chosen to invest in this training directly.
    We are in discussion with NHSE to develop a sustainably commissioned train-the-trainer service.
  7. What were the main facilitators / blockers / interdependencies when introducing this response?
    Funding is the key hurdle, but also the availability/capacity of Care Homes to be able to release staff for training.
Evaluation & Monitoring
  1. What are the key success measures?
    • Reduction in 999 calls
    • Confidence and competence of Care Home staff to respond to falls
    • Clearer processes to evaluate when an admission is required (NEWS2)
    • Reduction in calls from care homes to out of hours GPs
    • Reduction in calls from care homes to 999
    • Reduction in ambulance despatch and conveyance to accident and emergency departments
    • Reduction in admission to hospital with potential for extended length of stay
  2. How are these being measured / collated / monitored?  (frequency / who reported to etc)
    We routinely evaluate 999 calls from care homes to establish if there is a long-term trend in reduced call-outs.  From evaluation of over three years of data, we can confirm that initial reduction can be as high as 28%-32%, with longer-term reduction being around 7%-10%.  This gradual erosion of value is to be expected due to the high attrition of the care sector workforce. This is part of the reason we would recommend the sustainable commissioning of this training, alongside a wider focus on Care Home staff in general with other associated training.
  3. Has a formal evaluation process been undertaken (independent / inhouse)?
    In-house only, where we have evaluated 999 call-outs from the care homes trained, and a control group of care homes in the same area which have not received the training.  This process has been reviewed by NECS and NHSE and found to be robust.  Ongoing dialogue is taking place with Local Authorities who have recently re-commissioned the service.
  4. What are the current findings in terms of the success measures?
    Quantitative:  There remains circa 7%-10% long-term reduction of 999 call-outs from Care Homes which have received the training, in comparison with the control group.
    Qualitative:  Delegate feedback consistently shows attendance on the course builds confidence and competence; with feedback of trainer quality and course content being around 98% positive.  Anecdotal feedback from third parties, such as the CQC who have attended the course and Care Home Managers, also reflects the comments of the delegates.
  1. Does the trust intend to continue with this response for the foreseeable future?
    The Trust will continue to provide this training as part of our portfolio as long as customers / commissioners are willing and able to fund this.  We have held our prices firm for three years as part of our commitment to the value of this course.
    Any new trainers who join the team are required to be familiar with this element of the training portfolio.
  2. What long-term resourcing requirements are there?
    N/a.  The training team is in place, and can flexibly meet demand.
  3. What risks have been identified (for patients / trust / system) in providing this service and how have these been mitigated?
  4. Is there potential to expand this response model?
    Yes, assuming funding is available on a sustainable basis, we can easily increase our training team.  As above, we have held several meetings with NHSE North and have supported them in regional Care Home conferences.  There is some appetite for an expanded Train-the-Trainer model, but this remains subject to available funding. We remain in ongoing dialogue to discuss this.
Sharing & Learning
  1. What has the trust learnt most from introducing this process?
    Care Home staff are generally under-trained, under-invested in, and with some support of this nature can be considerably upskilled, feel more confident and make a significant difference in patient care, outcomes and experience.  With the right training programme of a few specific courses, Care Home staff could become a major part of the solution to the current pressure on Emergency Departments, as opposed to part of the problem. Anecdotally, this training can also positively influence a focus on reducing Care Home staff attrition.
    The Academic Health Science Network (AHSN) recognised the value of this course in their regional Bright Ideas in Health (BiHA) awards.  The award was for innovation in healthcare, related to the learning outcomes and impact of the training.
  2. What might be done differently with the benefit of hindsight if implementing again? (in another part of the trust for example)
    N/a.  The course has met every one of its targets.  There was extensive engagement with all relevant stakeholders in advance of implementation, and it was an overall success.
ScHARR Evaluation

This Initiative has been the subject of an evaluation review by ScHarr – read the report here.

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